Provider Demographics
NPI:1942329552
Name:E N T GRP OF CLEVELAND INC
Entity Type:Organization
Organization Name:E N T GRP OF CLEVELAND INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:WLADECKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-808-9469
Mailing Address - Street 1:805 COLUMBIA RD
Mailing Address - Street 2:SUITE #111
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-1487
Mailing Address - Country:US
Mailing Address - Phone:440-808-9469
Mailing Address - Fax:440-808-9532
Practice Address - Street 1:805 COLUMBIA RD
Practice Address - Street 2:SUITE #111
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-1487
Practice Address - Country:US
Practice Address - Phone:440-808-9469
Practice Address - Fax:440-808-9532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35059673W174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9930971Medicare PIN